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122 Original article

Anchor suture fixation for displaced tibial spine fractures

Hatem S.A. Elgohary and Naser M. Selim

Department of Orthopedic Surgery, Mansoura Background

University, Mansoura, Egypt
Correspondance to Hatem S.A. Elgohary, MD,
Department of Orthopedic Surgery, Mansoura
University, Mansoura, Egypt
Tel: + 20 100 659 3810; fax: + 20 502 799 288;
e-mail: hatemelgohary20@yahoo.com
Received 4 December 2010
Accepted 6 June 2011
Egyptian Orthopedic Journal
2013, 48:122–125
Treatment of displaced tibial spine fractures includes varied modalities. The goal of this
study was to assess the results of fixation of tibial spine fractures using anchor passing
nonabsorbable braided sutures through the substance of the anterior cruciate
ligament.
Patients and methods
Thirteen patients with displaced fractures of the anterior tibial spine were treated in
Mansoura emergency hospital with nonabsorbable suture fixation from January 2008
to October 2009; 11 patients were men and two were women. Ten cases were type III
and three were type IV following Meyers and McKeever’s classification; the evaluation
was performed using the Lachman test and anterior drawer test. The Lysholm score
was used as a functional evaluation score.
Results
Lachman and anterior drawer tests were negative in 10 cases and the other three
cases had mild positive tests. The mean postoperative Lysholm score was 96, ranging
from 88 to 100.
Conclusion
Anchor with suture fixation for displaced tibial spine fracture is a reliable technique with
excellent functional outcomes that does not need a further operation for implant
removal and with less potential breakage of the bone fragment than with the use of
screws. Also, the use of screws can be avoided as they have a tendency to migrate
into the bone substance.

Keywords:
anchor suture, anterior cruciate ligament, tibial spine

Egypt Orthop J 48:122–125

& 2013 The Egyptian Orthopaedic Association
1110-1148

of these, only 13 patients completed their follow-up and

Introduction
Avulsion fractures of the tibial spine account for only
1–5% of anterior cruciate ligament (ACL) injuries in
adults [1]. Meyers and McKeever [2] developed a system
for the classification of these fractures. In type I fractures,
the fragment is minimally displaced, type II fractures
show elevation of the anterior half of the fragment, and
type III fractures show complete displacement.
This system was modified by Zaricznyj [3], who
considered comminution of a displaced avulsion fracture
as a type IV fracture. Surgical intervention is indicated for
types II, III, and IV because displaced fractures may
cause nonunion or malunion as well as loss of knee
extension or instability [3–6].
The use of K-wires or screw fixation needs further
operation for implant removal in addition to the problems
of displaced implants and lack of rigid fixation; also, the
use of screws may lead to an increase in fragment
comminution. Hence in this study, open surgery and
anchor suture fixation of the fractures were used to avoid
these problems [7,8].
Sixteen patients with displaced fractures of the anterior
tibial spine were treated by open reduction and internal
fixation using an anchor fixed to nonabsorbable sutures;
1110-1148 & 2013 The Egyptian Orthopaedic Association
were included in this study. The results of surgery were
assessed clinically and radiologically. The functional
outcome was evaluated using the Lysholm knee scoring
system [9].
Patients and methods
In this study, 13 patients (11 men and two women) with
displaced fractures of the anterior tibial spine were
treated in Mansoura emergency hospital by open reduc-
tion and internal fixation using an anchor fixed to
nonabsorbable sutures in the period between January
2008 and October 2009 (Fig. 1).
The average age of the patients was 24 years (range,
19–42 years). The injury was because of road traffic
accidents in six patients and sports injury in seven.
Patients with associated major proximal tibial fractures
and children were excluded from the study. All cases were
fixed within 4 days of trauma. Fastin metal self-drilling
and self-tapping screwing 5 mm anchors were used.
Indication for surgery in these cases was type III and type
IV fractures according to Meyers and McKeever’s
classification [2].
DOI: 10.7123/01.EOJ.0000428842.13357.8a

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Tibial spine fractures Elgohary and Selim 123

Figure 1

A 20-year-old male patient with a displaced tibial spine fracture. (a) Preoperative anteroposterior view, (b) preoperative lateral view, (c) immediate
postoperative anteroposterior view after fixation with anchor suture, (d) immediate postoperative lateral view after fixation with anchor suture, (e)
anteroposterior view 15 months after fixation with anchor suture, tibial spine united, (f) lateral view 15 months after fixation with anchor suture, tibial
spine united.

With the patient lying supine, a tourniquet was inflated
after elevation of the lower limb for 5 min. Then, through
a medial parapatellar approach with a midline skin
incision, the fracture site was reached and the bed was
prepared. Then, the anchor was inserted deep into the
bone of the bed, the sutures were tied through holes
drilled into the fractured tibial spine, and passed through
the ACL. A knot was then tied; a second anchor was
needed in two cases as one anchor was not sufficient to
provide the required stability. After wound closure, a long
leg cast was applied until radiological union was achieved.
Patients were allowed to partially bear weight until
evidence of radiological union; then, full weight bearing
was allowed.
The patients were followed up every 2 weeks until union,
and then monthly until the last follow-up. The average
period of follow-up was 22 months (13–32 months).
Anterior laxity in the knee joint was checked using
Lachman’s and anterior drawer tests; when compared
with the opposite normal knee, knee function was
assessed using the Lysholm knee scoring scale, with
a maximum score of 100. Its main parameters are limping
(5 points), support (5 points), locking (15 points),
instability (25 points), pain (25points), swelling
(10 points), stair climbing (10 points), and squatting
(5 points), and the results were graded as excellent
(91–100), good (82–90), fair (60–81), and poor
(o60) [9]. A goniometer was used to record the range
of motion (ROM) of the knee joint.
Preoperative and postoperative anteroposterior and lateral
views were obtained for all patients and the radiographs
were assessed for union of fracture and fragment
displacement of the tibial eminence.
Results
Thirteen patients with displaced tibial spine fractures
were treated at Mansoura emergency hospital from
January 2008 to October 2009; 11 patients were men
and two were women. Ten cases were type III fractures

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124 Egyptian Orthopedic Journal
and three were type IV fractures following Meyers and
McKeever’s classification [2].
The average age of the patients was 24 years (range,
19–42 years). Patients were followed up for an average
period of 17 months. Mechanisms of trauma were road
traffic accidents in six patients and sports injury in seven.
All cases were fixed within 4 days of trauma. Anchor
sutures were used to fix the anterior tibial spine fracture,
mainly the medial eminence, which is more commonly
fractured.
In this study, at the last follow-up, patients had a median
Lysholm knee score of 96 (range, 88–100).
At the last follow-up, two patients had a sensation of
locking and only two had mild knee swelling after
prolonged heavy activities.
All patients achieved radiological union in an average of
7 weeks. No patients developed displacement of the
fracture. No significant difference in the ROM was found
on comparing the affected and nonaffected knees.
Ten of these patients had extension lag less than 51 at the
last follow-up. Three patients had mild degrees of
positive anterior Drawer and Lachman tests.
Discussion
The avulsion fracture of the anterior tibial spine can
easily be missed if not suspected. This injury is difficult
to observed in the anteroposterior view, but can be
observed more easily in the lateral view. The possibility of
a fractured tibial spine should therefore be considered in
all traumatized acutely swollen knees [10].
Various treatment options have been used for displaced
anterior tibial spine fractures including conservative
management, open or arthroscopic reduction, and internal
fixation [1,11–14]. In this series, 13 displaced type III
and type IV fractures were treated with open reduction
and internal fixation using an anchor fixed to nonabsorb-
able sutures; all our patients were immobilized in a
cylinder plaster cast at 0–101 of flexion until radiological
union.
Five patients had pain on severe exertion, whereas the
rest of the patients had no pain. No patient experienced
giving way of the knee; two patients had a sensation of
locking of the knee.
Although the treatment of nondisplaced tibial spine
fractures is straightforward, displaced fractures may be
complicated by nonunion loss of knee extension and/or
instability [2,8,15–18].
In the displaced avulsions of the tibial spine, internal
fixation is the treatment of choice; slight to moderate
anterior instability of little functional importance may
develop despite anatomical reduction, which may be
attributed to ligamentous elongation at the time of the
accident [19].
Copyright © The Egyptian Orthopaedic Association. Unauthorized reproduction of this article is prohibited.
In case the fracture fragment is comminuted or small,
sutures inserted through the substance of the ACL
enable secure fixation and provide even reduction with-
out requiring a second operation for implant removal and
with less potential breakage of the bone fragment than
with the use of screws [20,21].
Sharma et al. [10] carried out an analysis of different types
of surgical fixation for displaced anterior tibial spine
avulsion fractures with absorbable and nonabsorbable
materials. They found that adults fixed with nonabsorb-
able material showed significantly better results than
those fixed with absorbable material and that Herbert
screws had a tendency to migrate into the bone
substance, and are best avoided.
Vega et al. [22] carried out a study on arthroscopic fixation
of displaced tibial eminence fractures using an anchor
passing no absorbable braided sutures through the
substance of the ACL, holding the avulsed bone fragment
by tying a locking knot. They found that the anterior
drawer and Lachman tests were negative. The mean
Lysholm score was 94.
Fixation using anchors does not require drilling through
the growth plate as it is the case in fixation with pullout
sutures, thus sparing the growth plate in children [22].
Mahar et al. [23], in their biomechanical study, found that
Ethibond pullout sutures resulted in a deformation and
increased fracture separation, with a potential loss in
reduction during cyclic, physiologic loads. On using
anchors, the suture length is shorter, with less deforma-
tion theoretically; however, further comparative biome-
chanical study is required.
Rademakers et al. [24] carried out a long-term follow-up
study of open reduction and internal fixation of tibial
spine fractures. At the 1-year follow-up, the fracture had
completely healed in all patients. One patient (3%)
required revision of the osteosynthesis because of
hardware failure and one (3%) developed a deep
infection. The median knee ROM after 1 year was 1251
(range 110–1401). The Lysholm score showed good to
excellent results in 86% of the patients. It was concluded
that open reduction and internal fixation of tibial spine
fractures increases the possibility of regaining full
stability of the knee joint and good long-term results
with low infection rates. Knee function is adequately
restored in most patients.
May et al. [25] carried out a retrospective study on tibial
spine fractures. They studied the outcome of surgically
treated patients with tibial spine fractures and found that
patients with screw fixation had a higher reoperation rate
for removal of symptomatic hardware.
Chen et al. [26] carried out a study on arthroscopic
treatment of tibial spine avulsion fractures using no
absorbable suture fixation without postoperative immo-
bilization and found that the mean Lysholm score was
98.4 in cases of fresh fracture and 89.8 in cases of old
fracture.
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Conclusion
The use of an anchor with suture fixation for a displaced
tibial spine fracture is a reliable technique with excellent
functional outcomes that does not required a further
operation for implant removal and with less potential
breakage of the bone fragment than with the use of
screws. Also, the use of screws can be avoided as they
have the tendency to migrate into the bone substance.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
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